Saturday, July 20, 2013

Unlikely Miracles

We were pretty damn lucky that she was young and healthy.

The surgery had been technically successful. I watched as the resident finished with the last sutures. Although the attending had already left the room, I looked on with the eagerness of a third year student. Orders were written, and the patient was transferred to recovery.

It was a routine hysterectomy. None of the pizazz and flare of a gyne onc surgery, but at such an early stage in my career, I thought I was witnessing rocket science. We left the OR and rounded for the rest of the afternoon. As I hunkered in for a long evening in the hospital, I got a page from the resident.

Our hysterectomy dropped her blood pressure, meet me in her room!

The seen was serene. Our patients blood pressure was low indeed, but she was none the worse for it. Her belly was tender, but not alarmingly so given her recent surgery. We checked the numbers again manually, adjusted the fluids, and sent stat labs. We had no idea how long of a night we were in for.

As the hours passed the blood pressure continued to drop after each bolus of fluid. Serial blood counts showed that the hemoglobin was dropping disturbingly. I ordered a few units of packed red blood cells and listened to the resident arguing with the attending.

She's bleeding out. We need to go back to the OR now!

The attending, however, was unconvinced. In a strange haze of denial, she came up with any and every reason not to take the patient to the operating table. And so the resident and I sat at the bedside all night adjusting IV's, ordering more transfusions, and praying.

The miracle came around five o'clock the next morning. The hypotension resolved. The counts stabilized. Large purplish bruises outlined the patients abdomen and back, a reminder of the huge amounts of blood that had been lost. The resident and I figured that the fussy bleeder must have finally tamponaded.

The attending rounded in her usual fashion. She entered the patients room with an air of confidence. She turned to the resident smugly and barked off a few orders. It was clear that she was patting herself on the back for what she believed had been the right decision.

Years later, I still find it surprising that our patient survived the night. I have no doubt that the right thing to do would have been to return to the OR immediately and address the hemorrhage surgically.

And this seems to be the problem with difficult, involved decisions. Sometimes the decision makers are vested emotionally and otherwise. Often our vision is clouded, even when the correct path of action is undeniably staring us in the face.

As the drumbeat of healthcare reform marches on, there are those physicians and policymakers who call for greater regulation and more reporting.

Physicians like myself, working in the trenches, find ourselves backed into a familiar corner.

Our patient lies in the bed hemorrhaging, and we stand close by with both hands tied behind our backs hoping upon hope,